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Saving Babies 2012-2013: Ninth report on perinatal care in South Africa

Robert Pattinson and Natasha Rhoda for the PPIP group

The report can be viewed on www.ppip.co.za

Hardcopies and copies on CD-ROM are available from: The MRC Unit for Maternal and Infant Health Care Strategies

Klinikala Building, Kalafong Hospital Private Bag 667 PRETORIA, 0001

Tel/Fax: (012) 373-0825 E-mail: [email protected]

ISBN: 978-0-620-63308-6

Quoting the report:

Saving babies 2012-2013: Ninth report on perinatal care in South Africa. RC Pattinson, N Rhoda, Tshepesa Press, Pretoria, 2014

ISBN: 978-0-620-63308-6

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Acknowledgements We would like to thank the following, without whom the publication of this document would have been impossible:

• All the PPIP users: “All that is necessary for the triumph of evil is that good men do nothing”. Edmund Burke, Irish orator, philosopher, & politician (1729 - 1797). The PPIP users, sometimes under extremely difficult conditions, continue to support the programme and directly contribute to saving babies’ lives. They certainly are not “doing nothing”. This group of dedicated people is conducting more than half of the births in the public service of South Africa. There is a whole army of dedicated people working to improve the services for women and their babies!

• Mrs Roz Prinsloo who has coordinated PPIP, organised the multiple workshops all national meetings since the first in 2000 and compiled the book.

• The Department of Obstetrics and Gynaecology at the University of Pretoria for allowing the editor time to compile the report

• The Maternal, Child and Women’s Health and Nutrition Cluster of the National Department of Health for their continued support, work and enthusiasm

• The Provincial MCWH units for their continued support and work • The South African Medical Research Council for funding this project

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Contents

Section Page Acknowledgements ii Contents iii Foreword iv Abbreviations v

1 1.1 Introduction 2 1.2 Perinatal Care Indicators 3 1.3 Number of births and perinatal deaths per level of care and average per institution 6 1.4 Primary obstetric cause of death 10 1.5 Final causes of early neonatal death 18 1.6 Distribution of primary obstetric causes and timing of perinatal deaths 20 1.7 Route of delivery 21 1.8 Avoidable factors, missed opportunities and sub-standard care 22 1.9 Summary of findings 26

1.10 Recommendations 27

2 2.1 Mortality indices for provinces and districts for babies 500g+ (from PPIP 2012-2013) 30 2.2 Mortality indices for provinces and districts for babies 1000g+ (from PPIP 2012-2013) 32 2.3 Mortality ranked per district for PNMR, SBR and ENNDR (babies 1000g+) 34

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Foreword

This ninth Saving Babies report is meant to serve as a document of record and is available on the PPIP website (www.ppip.co.za ). The report has many tables and graphs giving information in different birth weight categories. The triennial National Perinatal Morbidity and Mortality Committee (NaPeMMCo) report will give a discussion and recommendations on perinatal care. The Saving Babies chapter in the NaPeMMCo report is a summary of this current report.

However, this report is novel in that it has calculated the average deliveries per site per level of care and not just the levels of care. This has been done to begin the discussion on staffing norms and what constitutes a safe maternity unit. This also helps health care managers look at the numbers of births in different birth weight categories which help examine the cost effectiveness of certain interventions such as nasal CPAP; i.e. how many babies need to be born between 1-2kg to justify the introduction of nasal CPAP so that enough cases are delivered so that the staff maintains its skills in the use of the equipment. 1st October 2014

Robert Pattinson MD, FRCOG, FCOG (SA) Director: SA MRC Maternal and Infant Health Care Strategies unit, Professor: Department of Obstetrics and Gynaecology, University of Pretoria Chief Specialist: Kalafong Tertiary Hospital

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Abbreviations APH Antepartum haemorrhage CA Congenital abnormalities CHC Community Health Centres CS Caesarean section DH District Hospitals DHIS District Health Information System ENND Early neonatal death ENNDR Early neonatal death rate FA Fetal abnormalities FSB Fresh Still Birth HT Hypertension Imm. Immaturity iMMR Institutional Maternal Mortality Ratio Inf. Infections IPA+T Intrapartum asphyxia and birth trauma IUGR Unexplained intrauterine growth restriction LBWR Low birth weight rate MD Pre-existing medical conditions NC National Central Hospital NOC No obstetric cause PCI Perinatal Care Index PND Perinatal death PNMR Perinatal mortality rate PPIP Perinatal Problem Identification Programme PT Provincial Tertiary Hospital RH Regional Hospitals SB Stillbirth SBR Stillbirth rate SPTB Spontaneous preterm birth T Birth Trauma U-SB Unexplained stillbirth Unk. Unknown

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Section 1

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1.1 Introduction During the period 1st January 2012 to 31st December 2013, 1,412,355 births and 32,662 stillbirths and 14,576 early neonatal deaths were recorded on the national Perinatal Problem Identification Programme (PPIP) database from 588 PPIP sites. This represents 75.6% of all births in institutions using the District Health Information System (DHIS) for the denominator (July 2014). Table 1 gives the comparison of births recorded on the DHIS and in PPIP. Four provinces have very complete PPIP data in relation to the DHIS, but three provinces the penetration of PPIP is a long way from complete.

Table 1. Comparison of births in the DHIS and PPIP (2012-2013)

EC FS Gau KZN Lim Mpu NW NC WC SA 500 - 999g 1415 1344 3848 2739 1778 1437 1263 711 3207 17742 1,000 - 1,499g 2429 1912 5228 3547 2949 2451 1926 912 3779 25133 1,500 - 1,999g 4381 3229 8801 5805 5449 4151 3218 1763 6912 43709 2,000 - 2,499g 12637 7635 25460 16193 15818 12618 9931 4409 18453 123154 2,500g+ 121509 75443 247319 176376 181835 135809 93009 30128 149198 1210626 PPIP Total 142371 89563 290656 204660 207829 156466 109347 37923 181549 1420364 DHIS Total 234841 94139 415840 381262 254249 153206 115828 43093 185821 1878279 Difference 92470 4576 125184 176602 46420 -3260 6481 5170 4272 457915 % missing from PPIP 39.4 4.9 30.1 46.3 18.3 -2.1 5.6 12.0 2.3 24.4

Table 2 gives the official classification of hospitals from the Government Gazette of August 2011.

Table 2. Distribution of hospitals in South Africa (2011)

Province District Hospital

Regional Hospital

Provincial Tertiary

National Central

Total Hospitals

Eastern Cape 38 1 3 1 43 Free State 15 5 0 1 21 Gauteng 10 9 0 4 23 KwaZulu-Natal 37 11 2 2 52 Limpopo 29 4 2 0 35 Mpumalanga 18 3 2 0 23 North West 12 3 2 0 17 Northern Cape 8 1 1 0 10 Western Cape 21 5 0 2 28 South Africa 188 42 12 10 252 PPIP SA 179 38 12 9 238

Note 1. Data for hospital classification was obtained from the Government Regulation Gazette No 34521 of 12

August 2011 2. Only hospitals conducting births included, specialised TB and orthopaedic hospitals excluded.

Table 3 gives the distribution of the PPIP sites according to level of care. All levels of care (Community Health Centres – CHCs – 229,933 births (16.2% of PPIP database), District Hospitals - 654,115 births (46.3% of PPIP database), Regional Hospitals - 389334 births (27.4% of PPIP database), Provincial Tertiary Hospitals – 69,470 births (4.9% of PPIP database), and National Central hospitals – 72,503 births (5.1% of PPIP database) were well represented. All 52 districts were

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represented. Late neonatal deaths were under reported and are excluded from this report. The mortality rates are very similar to those described in the 2011-2012 report.

1.2 Perinatal care indicators Table 3. Perinatal mortality rates from PPIP database 2012-2013

500g+ CHC DH RH PT NC SA (PPIP) Born alive 228006 640872 374675 66744 69396 1379693 Survive 227653 633682 368752 65379 67400 1362866 Early neonatal death 326 6731 4856 1117 1546 14576 Total deaths 2253 19974 16515 3843 4653 47238 Late neonatal death 27 459 1067 248 450 2251 Stillborn 1927 13243 11659 2726 3107 32662 total 229933 654115 386334 69470 72503 1412355

1000g+ CHC DH RH PT NC SA (PPIP) Born alive 227557 638262 371294 65700 67264 1370077 Survive 227288 632756 367476 64850 66041 1358411 Early neonatal death 242 5123 3060 669 907 10001 Total deaths 1670 15781 11649 2620 2835 34555 Late neonatal death 27 383 758 181 316 1665 Stillborn 1428 10658 8589 1951 1928 24554 Total 1000g+ 228985 648920 379883 67651 69192 1394631 PNMR 9.8 30.5 42.7 55.3 64.2 33.4 PNMR 1000g+ 7.3 24.3 30.7 38.7 41.0 24.8 SBR 8.4 20.2 30.2 39.2 42.9 23.1 SBR 1000g+ 6.2 16.4 22.6 28.8 27.9 17.6 ENNDR 1.4 10.5 13.0 16.7 22.3 10.6 ENNDR 1000g+ 1.1 8.0 8.2 10.2 13.5 7.3

Table 4. Perinatal care indicators per level of care 2010-2011

Community Health Centre

District Hospital

Regional Hospital

Provincial Tertiary

National Central

PNMR 9.57 33.43 39.50 51.04 63.30 PNMR 1000g+ 6.88 27.17 28.35 36.16 41.19 SBR 8.11 22.03 27.57 33.26 42.87 SBR 1000g+ 5.89 18.18 20.39 24.70 28.49 ENNDR 1.47 11.21 12.26 18.39 21.34 ENNDR 1000g+ 0.99 9.16 8.12 11.75 13.07

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Table 5 gives the PPIP perinatal care indices per level of care and figures 1-4 illustrate these indicators. District hospitals have the highest mortality rates between 1000g-2000g.

Table 5. PPIP perinatal care indices per level of care

SA CHC DH RH PT NC Perinatal Mortality Rate (/1,000) All deliveries 33.4 9.8 30.5 42.7 55.3 64.2 All 1,000g+ 24.8 7.3 24.3 30.7 38.7 41.0 500 - 999g 715.6 615.0 807.1 754.3 672.3 549.1 1,000 - 1,499g 347.6 253.4 463.1 337.0 276.5 225.7 1,500 - 1,999g 153.1 107.0 185.3 143.2 150.1 116.7 2,000 - 2,499g 47.6 19.5 49.9 53.7 58.2 50.2 2,500g+ 11.1 3.3 11.6 13.8 15.9 16.4 Early Neonatal Mortality Rate (/1,000) All deliveries 10.6 1.4 10.5 13.0 16.7 22.3 All 1,000g+ 7.3 1.1 8.0 8.2 10.2 13.5 500 - 999g 475.8 187.1 616.1 531.2 429.1 299.7 1,000 - 1,499g 153.1 43.0 238.1 147.1 106.3 92.1 1,500 - 1,999g 41.0 10.2 57.5 35.2 37.3 32.0 2,000 - 2,499g 11.0 2.7 12.2 12.1 12.1 13.2 2,500g+ 3.5 0.6 4.2 3.5 4.2 6.3 Stillbirth Rate (/1,000) All deliveries 23.1 8.4 20.2 30.2 39.2 42.9 All 1,000g+ 17.6 6.2 16.4 22.6 28.8 27.9 500 - 999g 457.5 526.4 497.6 475.9 426.1 356.1 1,000 - 1,499g 229.7 219.8 295.3 222.7 190.4 147.1 1,500 - 1,999g 116.9 97.8 135.6 112.0 117.1 87.5 2,000 - 2,499g 37.0 16.8 38.1 42.1 46.7 37.5 2,500g+ 7.7 2.7 7.4 10.3 11.7 10.2 Stillbirth / Neonatal Death Ratio 1.9 : 1 5.5 : 1 1.8 : 1 2.0 : 1 2.0 : 1 1.6 : 1 Perinatal Care Index All deliveries 2.3 1.0 2.5 2.4 2.4 2.1 All 1,000g+ 1.8 0.8 2.1 1.9 1.8 1.5

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

All deliveries All 1,000g+

PNM

R/10

00 b

irths

Figure 1. Comparison PNMR and level of care

SA

CHC

DH

RH

PT

NC

5

0.0

10.0

20.0

30.0

40.0

50.0

All deliveries All 1,000g+

SBR/

1000

birt

hs

Figure 2. Comparison SBR and level of care

SA

CHC

DH

RH

PT

NC

0.0

5.0

10.0

15.0

20.0

25.0

All deliveries All 1,000g+

ENN

DR/1

000

live

birt

hs

Figure 3. Comparison ENNDR and level of care

SA

CHC

DH

RH

PT

NC

0.0

0.5

1.0

1.5

2.0

2.5

3.0

All deliveries All 1,000g+

Perin

atal

Car

e In

dex

Figure 4. Comparison of PCI and level of care

SA

CHC

DH

RH

PT

NC

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The Perinatal Care Index (PCI) is highest in the district hospitals indicating a poorer quality of care.

1.3 Number of births and perinatal deaths per level of care and average per institution The number of births per birth weight category and level of care were calculated using the number of births recorded per level of care in the DHIS for 2012-2013 and annualised. This is shown in Table 6

Table 6. Estimated number of deliveries per year in birth weight categories and level of care

All births CHC DH RH PT NC 500 - 999g 748 3108 4087 2027 2660 1,000 - 1,499g 1122 4663 5529 2962 3239 1,500 - 1,999g 2431 9325 9616 4365 4338 2,000 - 2,499g 13091 31084 23318 8652 7172 2,500g+ 169616 340373 197842 59861 40427 Total 187007 388554 240392 77867 57835 Perinatal deaths 500 - 999g 460 2509 3083 1362 1461 1,000 - 1,499g 284 2159 1863 819 731 1,500 - 1,999g 260 1728 1377 655 506 2,000 - 2,499g 255 1551 1252 504 360 2,500g+ 560 3948 2730 952 663 Total 1819 11896 10305 4292 3721 Stillbirths 500 - 999g 394 1547 1945 864 947 1,000 - 1,499g 247 1377 1231 564 476 1,500 - 1,999g 238 1265 1077 511 380 2,000 - 2,499g 220 1184 982 404 269 2,500g+ 458 2519 2038 700 412 Total 1556 7891 7273 3043 2485 Live births 500 - 999g 742 3046 3963 1947 2546 1,000 - 1,499g 1113 4568 5362 2846 3100 1,500 - 1,999g 2411 9137 9325 4194 4152 2,000 - 2,499g 12981 30455 22614 8312 6864 2,500g+ 168194 333482 191872 57512 38695 Total 185440 380688 233137 74811 55357 ENND per year 500 - 999g 139 1876 2105 835 763 1,000 - 1,499g 48 1088 789 302 286 1,500 - 1,999g 25 525 328 156 133 2,000 - 2,499g 35 372 274 101 91 2,500g+ 101 1401 672 242 244 Total 347 5262 4168 1637 1516

Most of the deaths occur in the district hospitals as do most births. This is illustrated in figure 5. Figure 6 illustrates the estimated number of early neonatal deaths per weight category and level of care. Most deaths again occur in the district hospitals. The Government Gazette of 2011 listed 188 district hospitals, 42 regional hospitals, 12 provincial tertiary hospitals and 10 national central hospitals. Table 7 gives the estimated average number of births and early neonatal deaths per institution. This is illustrated in figures 7 and 8.

7

0.05.0

10.015.020.025.030.035.040.045.0

All births % All SB % ENND %

Perc

ent

Figure 5. Distribution of births, stillbirths and early neonatal deaths per level of care

CHC

DH

RH

PT

NC

0

500

1000

1500

2000

2500

500 - 999g 1,000 -1,499g

1,500 -1,999g

2,000 -2,499g

2,500g+

Num

ber

Figure 6. Estimated number of early neonatal deaths per level of care and birthweight category

CHC

DH

RH

PT

NC

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Table 7. Average number of births and live births and stillbirths and early neonatal deaths per hospital per birth weight category

DH RH PT NC South Africa hospitals per Level of Care 188 42 12 10 Average births per year per hospital 500 - 999g 17 97 169 266 1,000 - 1,499g 25 132 247 324 1,500 - 1,999g 50 229 364 434 2,000 - 2,499g 165 555 721 717 2,500g+ 1810 4711 4988 4043 Total 2067 5724 6489 5784 Average Stillbirths per hospital per year 500 - 999g 8 46 72 95 1,000 - 1,499g 7 29 47 48 1,500 - 1,999g 7 26 43 38 2,000 - 2,499g 6 23 34 27 2,500g+ 13 49 58 41 Total 42 173 254 248 Average live births per hospital per year 500 - 999g 16 94 162 255 1,000 - 1,499g 24 128 237 310 1,500 - 1,999g 49 222 349 415 2,000 - 2,499g 162 538 693 686 2,500g+ 1774 4568 4793 3869 Total 2025 5551 6234 5536 Average ENNDs per hospital per year 500 - 999g 10 50 70 76 1,000 - 1,499g 6 19 25 29 1,500 - 1,999g 3 8 13 13 2,000 - 2,499g 2 7 8 9 2,500g+ 7 16 20 24 Total 28 99 136 152

0

1000

2000

3000

4000

5000

6000

500 - 999g 1,000 -1,499g

1,500 -1,999g

2,000 -2,499g

2,500g+

Num

ber

Figure 7. Average live births per hospital type per year

DH

RH

PT

NC

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In summary, most deaths occur in district hospital as do most births. The mortality rates in the district hospitals are the highest, BUT one district hospital on average will deliver a live born baby between 1000g and 1999g once every 5 days, and 12% (one in eight will be an early neonatal death). That is for the average district hospital delivering 2000 babies per year. If the hospital delivery 500 births per year, then they will deliver a live born between 1000g and 1999g every 20 days and two will die. This analysis raises the question of what resources should be available in each institution and how many deliveries per year will make the intervention cost-effective, while at the same time keeping health care accessible to the population.

The “CSIR Guidelines for the Provision of Social Facilities in South African Settlements” ( First Edition: CSIR August 2012) is a guideline document which “seeks to provide a quantitative and rational framework for the provision of key social facilities for various levels of settlements to support the planning process and provide support to the social facility investment plans”. The norms given in this guideline are a Level 3 hospital for 2.4 million population, a regional hospital per 1.77 million population (level 2); a district hospital per 300000-900000population with an access distance of 30km (Level 1); a community health centre for every 60000-140000 population with 90% access distance of 5km and a primary health care clinic for every 40000 population with an access distance of 5km. Using these figures and the population estimates of Stats SA mid-year estimated for 2013 (Statistical release P0302) it suggests South Africa should have:

• 22 tertiary hospitals – Level 3 (we have 22) • 30 regional hospitals – Level 2 (we have 42) • Between 59 and 177 district hospitals – Level 1 (we have 188)

It appears we have too many facilities for the population of the country. It is difficult to staff facilities and if there are too many, it means that the health care providers are spread more thinly on the ground and the quality of care will inevitably suffer.

0102030405060708090

500 - 999g 1,000 -1,499g

1,500 -1,999g

2,000 -2,499g

2,500g+

Num

ber

Figure 8. Average number of ENNDs per hospital type per year

DH

RH

PT

NC

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1.4 Primary obstetric cause of death Table 8 gives the mortality rates per primary obstetric cause and time of death for the levels of care. Some sites only complete the monthly statistic form of PPIP and do not complete the analysis of each death. A correction was made per level of care to factor these missing cases in.

Table 8. Mortality rates per primary obstetric cause and time of deaths for the levels of care

CHC DH RH PT NC

500g+ MSB Antepartum haemorrhage 0.13 0.56 2.63 3.26 2.75 Fetal abnormality 0.04 0.21 0.41 0.78 1.33 Hypertensive disorders 0.30 2.73 4.20 6.45 4.98 Infections 0.27 0.55 0.62 0.63 0.87 Intrapartum asphyxia 0.18 0.58 0.74 0.73 0.48 Unexplained Stillbirth 2.80 7.14 8.26 10.49 5.19 Intrauterine growth retardation 0.13 0.30 0.83 0.09 1.25 Maternal disease 0.08 0.38 0.56 0.90 1.27 Miscellaneous 0.03 0.13 0.25 0.40 0.76 No obstetric cause / Not applicable 0.02 0.07 0.18 0.11 0.07 Spontaneous preterm labour 0.48 0.89 1.07 1.50 1.54 Trauma 0.03 0.07 0.05 0.05 0.03 Total 4.49 13.62 19.80 25.39 20.51 500g+ FSB Antepartum haemorrhage 0.18 1.00 3.10 4.10 7.36 Fetal abnormality 0.10 0.17 0.33 0.65 2.38 Hypertensive disorders 0.14 0.29 1.57 2.97 4.82 Infections 0.16 0.11 0.23 0.17 0.38 Intrapartum asphyxia 1.16 1.85 1.62 2.07 1.37 Unexplained Stillbirth 1.10 0.54 1.43 1.80 1.68 Intrauterine growth retardation 0.03 0.04 0.16 0.06 0.31 Maternal disease 0.02 0.04 0.11 0.11 0.49 Miscellaneous 0.06 0.06 0.03 0.14 0.39 No obstetric cause / Not applicable 0.02 0.03 0.10 0.00 0.14 Spontaneous preterm labour 0.91 0.94 1.64 1.69 2.90 Trauma 0.02 0.02 0.05 0.06 0.10 Total 3.89 5.10 10.38 13.84 22.33

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Table 8. Mortality rates per primary obstetric cause and time of deaths for the levels of care (cont.)

CHC DH RH PT NC

500g+ SBR Antepartum haemorrhage 0.30 1.56 5.73 7.36 10.11 Fetal abnormality 0.14 0.39 0.74 1.42 3.71 Hypertensive disorders 0.44 3.03 5.77 9.43 9.80 Infections 0.43 0.66 0.86 0.81 1.25 Intrapartum asphyxia 1.34 2.43 2.36 2.80 1.85 Unexplained Stillbirth 3.91 7.69 9.69 12.29 6.86 Intrauterine growth retardation 0.16 0.34 0.99 0.16 1.56 Maternal disease 0.10 0.42 0.67 1.01 1.76 Miscellaneous 0.09 0.19 0.28 0.54 1.16 No obstetric cause / Not applicable 0.03 0.10 0.28 0.11 0.21 Spontaneous preterm labour 1.39 1.83 2.71 3.20 4.44 Trauma 0.04 0.09 0.10 0.11 0.13 Total 8.38 18.71 30.18 39.23 42.84 500g+ ENND Antepartum haemorrhage 0.04 0.37 0.60 1.00 1.00 Fetal abnormality 0.10 0.57 0.78 1.36 1.93 Hypertensive disorders 0.02 0.33 1.31 2.50 3.93 Infections 0.09 0.49 0.52 0.47 0.33 Intrapartum asphyxia 0.37 3.25 2.72 3.17 2.96 Unexplained Stillbirth 0.02 0.04 0.03 0.02 0.03 Intrauterine growth retardation 0.03 0.12 0.11 0.15 0.19 Maternal disease 0.00 0.11 0.19 0.16 0.30 Miscellaneous 0.07 0.15 0.10 0.20 3.20 No obstetric cause / Not applicable 0.14 0.33 0.38 1.00 0.82 Spontaneous preterm labour 0.54 4.70 6.21 6.66 7.58 Trauma 0.02 0.02 0.02 0.04 0.00 Total 1.43 10.48 12.96 16.73 22.29 500g+ PNMR Antepartum haemorrhage 0.34 1.92 6.30 8.31 11.07 Fetal abnormality 0.24 0.95 1.50 2.73 5.55 Hypertensive disorders 0.46 3.36 7.05 11.83 13.56 Infections 0.52 1.14 1.36 1.26 1.57 Intrapartum asphyxia 1.71 5.62 5.00 5.85 4.68 Unexplained Stillbirth 3.92 7.72 9.71 12.32 6.89 Intrauterine growth retardation 0.19 0.46 1.10 0.30 1.75 Maternal disease 0.10 0.53 0.85 1.17 2.05 Miscellaneous 0.16 0.33 0.38 0.73 4.22 No obstetric cause / Not applicable 0.17 0.42 0.65 1.07 1.00 Spontaneous preterm labour 1.93 6.44 8.73 9.60 11.70 Trauma 0.06 0.11 0.11 0.15 0.13 Total 9.80 29.00 42.75 55.31 64.17

The top three conditions are shown in pink, orange and yellow for each level of care. In the lower levels of care the major causes are unexplained stillbirths, spontaneous preterm labour and intrapartum asphyxia; whereas in the higher levels of care complications of hypertension, antepartum haemorrhage and spontaneous preterm labour have higher mortality rates.

The mortality rates shown in Table 6 and 8 were used to calculate the numbers of deaths per year, per level of care using facility births data from the DHIS and the numbers are is shown in Tables 9 and 11.

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Table 9. Number of deaths per condition, per level of care. (Extrapolated from DHIS births data and PPIP mortality rates per condition - estimate per annum the number of deaths).

500g+ PND per year per LOC CHC DH RH PT NC Total Antepartum haemorrhage 63 748 1516 648 640 3615 Fetal abnormality 46 369 360 213 321 1309 Hypertensive disorders 85 1304 1694 922 784 4790 Infections 97 443 328 98 91 1056 Intrapartum asphyxia 320 2183 1201 456 271 4430 Unexplained Stillbirth 734 3000 2335 960 399 7427 Intrauterine growth retardation 36 180 265 24 101 605 Maternal disease 19 205 205 91 118 637 Miscellaneous 30 129 92 57 244 552 No obstetric cause / Not applicable 32 164 157 83 58 493 Spontaneous preterm labour 360 2502 2098 748 677 6385 Trauma 12 43 27 11 7 101 Total 1832 11268 10277 4311 3711 31399 500g+ SBR Antepartum haemorrhage 57 605 1377 573 585 3196 Fetal abnormality 27 150 178 111 214 681 Hypertensive disorders 83 1177 1388 735 567 3949 Infections 81 255 206 63 73 677 Intrapartum asphyxia 251 945 568 218 107 2088 Unexplained Stillbirth 731 2987 2329 958 397 7402 Intrauterine growth retardation 30 133 239 12 90 505 Maternal disease 19 162 161 79 102 522 Miscellaneous 17 72 68 42 67 266 No obstetric cause / Not applicable 6 39 68 9 12 134 Spontaneous preterm labour 259 712 651 249 257 2128 Trauma 8 35 23 9 7 82 Total 1567 7271 7255 3058 2478 21628 500g+ ENND Antepartum haemorrhage 7 143 139 75 55 418 Fetal abnormality 19 219 182 102 107 628 Hypertensive disorders 3 127 306 187 218 841 Infections 16 188 122 35 18 379 Intrapartum asphyxia 69 1236 633 238 164 2340 Unexplained Stillbirth 3 13 6 2 2 26 Intrauterine growth retardation 6 47 26 11 11 100 Maternal disease 0 43 44 12 17 116 Miscellaneous 13 56 24 15 177 285 No obstetric cause / Not applicable 25 125 89 75 46 359 Spontaneous preterm labour 101 1787 1447 499 420 4254 Trauma 4 8 4 3 0 19 Total 265 3991 3022 1253 1234 9764 Estimated per Annum All deaths 1832 11262 10277 4311 3711 31393 All births 500g+ per year 187007 388554 240392 77945 57835 961372 PNMR 9.80 28.98 42.75 55.31 64.17 32.65

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Tables 10 and 11 give the same information for babies 1000g+.

0

500

1000

1500

2000

2500

3000

3500

APH FA HT Inf. IPA U-SB IUGR MD SPTB

Num

ber

Disease category

Figure 5. Comparison of number of PNDs per disease category per level of care (500g+)

CHC

DH

RH

PT

NC

0

500

1000

1500

2000

2500

3000

3500

APH FA HT Inf. IPA U-SB IUGR MD SPTB

Num

ber

Disese category

Figure 6. Comparison of the number of stillbirths per disease category and level of care (500g+)

CHC

DH

RH

PT

NC

0

500

1000

1500

2000

APH FA HT Inf. IPA U-SB IUGR MD SPTB

Num

ber

Disease category

Figure 7. Comparison of the number of ENNDs per disease category per level of care (500g+)

CHC

DH

RH

PT

NC

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Table 10. Mortality rates per primary obstetric cause and time of deaths for the levels of care

CHC DH RH PT NC

1000g+ MSB Antepartum haemorrhage 0.08 0.47 2.27 2.72 2.38 Fetal abnormality 0.04 0.18 0.34 0.62 0.90 Hypertensive disorders 0.21 2.19 2.85 4.13 2.97 Infections 0.21 0.46 0.51 0.55 0.65 Intrapartum asphyxia 0.17 0.56 0.68 0.66 0.47 Unexplained Stillbirth 2.15 5.88 6.49 8.27 4.04 Intrauterine growth retardation 0.08 0.24 0.66 0.08 0.80 Maternal disease 0.05 0.36 0.52 0.79 1.05 Miscellaneous 0.03 0.11 0.19 0.28 0.64 No obstetric cause / Not applicable 0.01 0.05 0.16 0.08 0.06 Spontaneous preterm labour 0.23 0.51 0.58 0.66 0.38 Trauma 0.02 0.05 0.04 0.05 0.01 Total 3.27 11.07 15.28 18.89 14.36 1000g+ FSB Antepartum haemorrhage 0.12 0.88 2.60 3.59 6.25 Fetal abnormality 0.11 0.15 0.27 2.09 1.26 Hypertensive disorders 0.10 0.26 0.87 1.72 1.52 Infections 0.13 0.09 0.16 1.15 0.21 Intrapartum asphyxia 1.17 1.84 1.60 0.52 1.38 Unexplained Stillbirth 0.82 0.43 1.01 0.50 1.29 Intrauterine growth retardation 0.03 0.04 0.13 0.11 0.18 Maternal disease 0.01 0.02 0.09 0.10 0.33 Miscellaneous 0.04 0.04 0.02 0.06 0.25 No obstetric cause / Not applicable 0.02 0.02 0.08 0.06 0.13 Spontaneous preterm labour 0.40 0.35 0.47 0.05 0.62 Trauma 0.02 0.01 0.03 0.00 0.09 Total 2.97 4.14 7.33 9.95 13.50 1000g+ SBR Antepartum haemorrhage 0.21 1.35 4.87 6.31 8.63 Fetal abnormality 0.14 0.33 0.60 2.70 2.16 Hypertensive disorders 0.31 2.45 3.72 5.84 4.49 Infections 0.33 0.55 0.67 1.70 0.86 Intrapartum asphyxia 1.35 2.41 2.28 1.18 1.85 Unexplained Stillbirth 2.97 6.31 7.50 8.77 5.32 Intrauterine growth retardation 0.11 0.28 0.79 0.19 0.98 Maternal disease 0.06 0.39 0.61 0.89 1.38 Miscellaneous 0.07 0.15 0.22 0.34 0.89 No obstetric cause / Not applicable 0.02 0.07 0.24 0.15 0.19 Spontaneous preterm labour 0.62 0.86 1.05 0.71 1.01 Trauma 0.03 0.07 0.07 0.05 0.10 Total 6.24 15.21 22.62 28.84 27.85 1000g+ ENND Antepartum haemorrhage 0.03 0.26 0.41 0.52 0.62 Fetal abnormality 0.10 0.57 0.73 1.17 1.84 Hypertensive disorders 0.01 0.28 0.65 1.22 1.64 Infections 0.07 0.44 0.44 0.40 0.27 Intrapartum asphyxia 0.36 3.23 2.72 2.91 2.91 Unexplained Stillbirth 0.01 0.03 0.02 0.02 0.03 Intrauterine growth retardation 0.03 0.12 0.09 0.13 0.11 Maternal disease 0.00 0.09 0.12 0.07 0.27 Miscellaneous 0.06 0.13 0.09 0.14 2.11 No obstetric cause / Not applicable 0.13 0.31 0.35 0.90 0.80 Spontaneous preterm labour 0.22 2.54 2.60 2.67 2.87 Trauma 0.02 0.01 0.02 0.04 0.00 Total 1.06 8.02 8.24 10.18 13.48

15

Table 10. Mortality rates per primary obstetric cause and time of deaths for the levels of care

CHC DH RH PT NC

1000g+ PNMR Antepartum haemorrhage 0.24 1.61 5.27 6.81 9.24 Fetal abnormality 0.24 0.89 1.32 3.84 3.94 Hypertensive disorders 0.33 2.73 4.35 7.03 6.09 Infections 0.41 0.98 1.10 2.09 1.12 Intrapartum asphyxia 1.71 5.58 4.94 4.00 4.68 Unexplained Stillbirth 2.99 6.34 7.52 8.80 5.35 Intrauterine growth retardation 0.14 0.39 0.88 0.32 1.08 Maternal disease 0.06 0.48 0.73 0.96 1.64 Miscellaneous 0.13 0.27 0.30 0.48 2.94 No obstetric cause / Not applicable 0.16 0.38 0.58 1.02 0.97 Spontaneous preterm labour 0.84 3.37 3.60 3.31 3.79 Trauma 0.05 0.08 0.08 0.08 0.10 Total 7.29 23.10 30.67 38.73 40.96

16

Table 11. Number of deaths per condition, per level of care. (Extrapolated from DHIS births data and PPIP mortality rates per condition - estimate per annum the number of deaths).

CHC DH RH PT NC Total 1000g+ number per year Antepartum haemorrhage 44 623 1255 523 517 2963 Fetal abnormality 46 343 313 295 221 1218 Hypertensive disorders 61 1056 1037 539 341 3034 Infections 76 379 262 160 63 941 Intrapartum asphyxia 319 2160 1177 307 262 4226 Unexplained Stillbirth 558 2453 1792 675 300 5777 Intrauterine growth retardation 26 151 209 25 60 471 Maternal disease 11 184 173 74 92 534 Miscellaneous 24 105 71 37 165 401 No obstetric cause / Not applicable 29 147 139 78 55 448 Spontaneous preterm labour 157 1302 857 254 212 2783 Trauma 10 32 20 6 6 74 Total 1361 8937 7306 2971 2294 22869

PNMR 1000g+ 7.29 23.10 30.67 38.73 40.96 24.22 1000g+ SBR Antepartum haemorrhage 38 523 1160 484 484 2689 Fetal abnormality 27 128 144 207 121 627 Hypertensive disorders 58 948 885 448 252 2591 Infections 62 212 161 130 48 614 Intrapartum asphyxia 251 931 543 91 103 1920 Unexplained Stillbirth 555 2442 1787 673 298 5755 Intrauterine growth retardation 21 107 188 15 55 385 Maternal disease 11 149 146 68 77 451 Miscellaneous 12 57 51 26 50 196 No obstetric cause / Not applicable 4 27 56 11 11 110 Spontaneous preterm labour 116 333 251 55 56 812 Trauma 6 27 16 4 6 58 Total 1164 5883 5387 2212 1560 16207

SBR 1000g+ 6.24 15.21 22.62 28.84 27.85 17.16 1000g+ ENND Antepartum haemorrhage 6 100 94 38 33 270 Fetal abnormality 18 213 167 85 97 581 Hypertensive disorders 3 107 149 89 87 435 Infections 14 166 100 29 14 323 Intrapartum asphyxia 67 1219 624 212 154 2276 Unexplained Stillbirth 3 11 5 2 2 22 Intrauterine growth retardation 6 44 21 9 6 86 Maternal disease 0 35 27 5 14 82 Miscellaneous 11 48 19 10 111 200 No obstetric cause / Not applicable 25 119 81 66 42 333 Spontaneous preterm labour 41 961 597 195 152 1944 Trauma 4 5 4 3 0 16 Total 196 3027 1890 743 712 6568

ENNDR 1000g+ 1.06 8.02 8.24 10.18 13.48 7.16

17

0

500

1000

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APH FA HT Inf. IPA U-SB IUGR MD SPTB

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Figue 8. Comparison of number of PNDs, per disease category, per level of care (1000g+)

CHC

DH

RH

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APH FA HT Inf. IPA U-SB IUGR MD SPTB

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Figure 9. Comparison of number of stillbirths per disease category and level of care (1000g+)

CHC

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APH FA HT Inf. IPA U-SB IUGR MD SPTB

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Figure 10. Comparison of ENNDs per disease category and level of care (1000g+)

CHC

DH

RH

PT

NC

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1.5 Final causes early neonatal death (ENND) Tables 12 and 13 give the early neonatal death rate per final cause of deaths and tables 14 and 15 give the estimated number of deaths per final cause of death and level of care per year.

Table 12. Final causes of early neonatal deaths expressed per 1000 live births for the levels of care (500g+ and 1000g+)

CHC DH RH PT NC SA ENNDR 500g+ Congenital abnormalities 0.09 0.69 0.96 1.81 2.90 0.83 Hypoxia 0.48 3.63 3.34 4.35 4.35 3.11 Immaturity related 0.51 4.94 6.85 7.47 11.20 5.17 Infection 0.14 0.43 1.03 2.00 2.62 0.73 Miscellaneous 0.11 0.48 0.54 0.68 0.64 0.46 Trauma 0.02 0.07 0.08 0.15 0.03 0.07 Unknown cause of death 0.07 0.22 0.16 0.27 0.54 0.20 Total 1.43 10.47 12.96 16.74 22.28 10.56 ENNDR 1000g+ Congenital abnormalities 0.09 0.67 0.90 1.56 2.78 0.78 Hypoxia 0.46 3.59 3.30 3.96 4.24 3.04 Immaturity related 0.19 2.59 2.56 2.23 3.45 2.21 Infection 0.13 0.40 0.82 1.49 2.03 0.60 Miscellaneous 0.11 0.47 0.45 0.57 0.55 0.41 Trauma 0.01 0.07 0.07 0.13 0.02 0.06 Unknown cause of death 0.06 0.21 0.14 0.25 0.43 0.18 Total 1.06 8.00 8.24 10.18 13.48 7.29

Table 13. Final causes of early neonatal deaths expressed per number of death per level of care per annum (500g+ and 1000g+)

Estimated numbers using DHIS birth data CHC DH RH PT NC SA

ENND number 500g+ Congenital abnormalities 17 262 225 135 161 800 Hypoxia 90 1383 779 325 241 2818 Immaturity related 94 1881 1597 559 620 4751 Infection 26 165 240 150 145 726 Miscellaneous 21 184 127 51 36 419 Trauma 4 28 18 11 2 63 Unknown cause of death 13 84 37 21 30 185 Total 265 3987 3022 1253 1233 9760 ENND number 1000g+ Congenital abnormalities 17 254 206 114 147 738 Hypoxia 86 1355 757 289 224 2711 Immaturity related 36 979 587 162 182 1946 Infection 24 152 188 109 107 580 Miscellaneous 20 177 103 42 29 371 Trauma 3 27 16 9 1 56 Unknown cause of death 11 79 32 18 22 162 Total 196 3023 1889 743 712 6563

19

0

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CA Hyp Imm R Inf.

Num

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Figure 11. Comparison of numbers of ENNDs per final cause of death and level of care (500g+)

CHC

DH

RH

PT

NC

0200400600800

1000120014001600

CA Hyp Imm R Inf.

Num

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Final cause of death

Figure 12. Comparison of number of ENNDs per final cause of death and level of care (1000g+)

CHC

DH

RH

PT

NC

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1.6 Distribution of primary obstetric causes and timing of perinatal deaths

There are 5 main primary obstetric categories of perinatal deaths (Unexplained stillbirth, intrapartum asphyxia, spontaneous preterm birth, hypertension and antepartum haemorrhage). Unexplained stillbirth is most common irrespective of whether 500g+ or 1000g+ is used for comparison. Spontaneous preterm birth and intrapartum asphyxia interchange the second and third places depending on the birth weight selected. Antepartum haemorrhage and hypertension are the next two categories. All other categories are minor compared with these 5 groups.

The importance of the unexplained stillbirth category has been ignored mostly because there is no apparent immediate intervention. It is estimated that the major causes of the unexplained stillbirths are undiagnosed intrauterine growth restriction and post-maturity, congenital infections and congenital abnormalities. PPIP v3 now includes gestation age as one of its data items; this now enables the estimation of growth of the perinatal deaths. When growth charts were applied to the unexplained stillbirth group a third of them are below the 10th centile for the growth charts of

0.05.0

10.015.020.025.030.035.040.045.050.0

SB% ENND% PND%

Perc

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Figure 13. Distribution of timing and primary obstetric causes of perinatal deaths (500g+)

APH

FA

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Figure 14. Distribution of primary obstetric causes and timing of perinatal deaths (1000g+)

APH

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SPTB

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Theron. This means of the unexplained stillbirths close to 2500 stillbirths over 500g and 1900 stillbirths over 2500g are potentially growth restricted. The condition of the mother is recorded at the time of birth and the vast majority of these mothers are reported as normal, i.e. no maternal condition was identified. The only way these babies could be detected would be if the fetus was identified as growing poorly or at risk in another way. To detect poor fetal growth symphysis fundus measurements are used, but these have a very poor ability to detect growth restricted babies. Another method would be to provide routine ultrasound scanning for all pregnant women. The public health system does not have the resources to implement this now. An option not tested at this stage is the use of continuous wave Doppler ultrasound for screening for growth restricted foetuses in the whole population. This has not been done before, and must be a high research priority. The CSIR along with the SA MRC has developed an Umbiflow apparatus that provides continuous wave Doppler ultrasound and can be linked to a normal laptop computer. This might bridge the device gap and allow for effective screening for growth restricted foetuses without the need for growth scans used in ultrasound.

1.7 Route of delivery The route of delivery per level of care is shown in tables 14 and 15.

Table 14. Distribution of route of delivery and level of care for 2012-2013 (PPIP data)

CHC DH RH PT NC SA Normal vaginal delivery 216892 482966 228295 39295 25382 992830 Ventouse delivery 169 3357 1594 254 451 5825 Forceps delivery 75 1219 624 89 143 2150 Vaginal breech delivery 1177 6021 3137 853 596 11784 Caesarean section 88 123281 125930 21958 24129 295386 Other (Destructive etc) 0 5 0 6 0 11 Delivery method unknown 11532 37261 26754 7015 21799 104361 Total 229933 654110 386334 69470 72500 1412347

Table 14. Distribution in percent of route of delivery and level of care for 2012-2013 (PPIP data)

Known route of delivery per level of care (%) CHC DH RH PT NC SA Normal vaginal delivery 99.3 78.3 63.5 62.9 50.1 75.9 Ventouse delivery 0.1 0.5 0.4 0.4 0.9 0.4 Forceps delivery 0.0 0.2 0.2 0.1 0.3 0.2 Vaginal breech delivery 0.5 1.0 0.9 1.4 1.2 0.9 Caesarean section 0.0 20.0 35.0 35.2 47.6 22.6 Other (Destructive etc) 0.0 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Distribution of known route of delivery within level of care (%)

Normal vaginal delivery 21.8 48.6 23.0 4.0 2.6 100.0 Ventouse delivery 2.9 57.6 27.4 4.4 7.7 100.0 Forceps delivery 3.5 56.7 29.0 4.1 6.7 100.0 Vaginal breech delivery 10.0 51.1 26.6 7.2 5.1 100.0 Caesarean section 0.0 41.7 42.6 7.4 8.2 100.0 Other (Destructive etc) 0.0 45.5 0.0 54.5 0.0 100.0 Total 16.7 47.2 27.5 4.8 3.9 100.0

Most caesarean sections are performed in district and regional hospitals. There are 42 regional hospitals which give an average number of caesarean section per hospital at approximately 4 per

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day. There are 188 district hospitals and they are performing 1 caesarean section per day. This is for average district hospital conducting 2000 births per year. If the hospital is only conducting 500 births per year, then the number of caesarean sections is likely to be 1 or less per week. Can the skilled be maintained of the doctors give anaesthetic and doing the surgery at such a level?

1.8 Avoidable factors, missed opportunities and sub-standard care Table 14 gives an overview of the number and distribution of cases per level of care where avoidable factors, missed opportunities and substandard care probably resulted in the death of the baby.

Table 14. Comparison of avoidable factors that probably resulted in the death of the infant (as assessed by their maternity unit) by level of care

CHC DH RH PT NC

Description N % of deaths N % of

deaths N % of deaths N % of

deaths N % of deaths

Total deaths 1828 18938 12123 4230 4931 Administrative problems 80 4.4 1547 8.2 1034 8.5 345 8.2 159 3.2 Health care provider associated 221 12.1 4645 24.5 2670 22.0 932 22.0 476 9.7 Patient and family associated 630 34.5 5976 31.6 2938 24.2 1198 28.3 767 15.6 Insufficient notes to comment on avoidable factors 33 1.8 232 1.2 185 1.5 62 1.5 198 4

Table 15. Avoidable factors that probably impacted on the death of an infant (as assessed by their maternity unit) for each major disease category for babies over 500g

Birth Asphyxia (500g+) Number % of deaths

Deaths due to asphyxia 6082 HEALTH CARE PROVIDER ASSOCIATED 2990 49.2 PATIENT AND FAMILY ASSOCIATED 1136 18.7 ADMINISTRATIVE PROBLEMS 960 15.8 Fetal distress not detected intrapartum; fetus monitored 510 8.4 Delay in seeking medical attention during labour 420 6.9 Fetal distress not detected intrapartum; fetus not monitored 282 4.6 Delay in referring patient for secondary/tertiary treatment 273 4.5 Delay in medical personnel calling for expert assistance 201 3.3 Management of 2nd stage: prolonged with no intervention 188 3.1 Booked late in pregnancy 184 3.0 Inappropriate response to poor fetal movements 177 2.9 Anaesthetic delay 151 2.5 Medical personnel underestimated fetal size 145 2.4

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Table 15. Avoidable factors that probably impacted on the death of an infant (as assessed by their maternity unit) for each major disease category for babies over 500g (cont.)

Spontaneous preterm birth (500g+) Number % of deaths

Deaths due to spontaneous preterm birth 9273 PATIENT AND FAMILY ASSOCIATED 2826 30.5 HEALTH CARE PROVIDER ASSOCIATED 1503 16.2 ADMINISTRATIVE PROBLEMS 970 10.5 Delay in seeking medical attention during labour 977 10.5 Never initiated antenatal care 815 8.8 Inadequate facilities/equipment in neonatal unit/nursery 407 4.4 Booked late in pregnancy 284 3.1 Inappropriate response to poor fetal movements 190 2.0 Neonatal care: management plan inadequate 182 2.0 Nosocomial infection 161 1.7 No accessible neonatal ICU bed with ventilator 123 1.3 Delay in referring patient for secondary/tertiary treatment 116 1.3 Neonatal care: inadequate monitoring 115 1.2 Antenatal steroids not given 112 1.2 Neonatal resuscitation inadequate 107 1.2

Antepartum Haemorrhage Number % of deaths

Deaths due to antepartum haemorrhage 4354 PATIENT AND FAMILY ASSOCIATED 1129 25.9 HEALTH CARE PROVIDER ASSOCIATED 691 15.9 ADMINISTRATIVE PROBLEMS 232 5.3 Never initiated antenatal care 233 5.4 Inappropriate response to antepartum haemorrhage 203 4.7 Inappropriate response to poor fetal movements 173 4 Booked late in pregnancy 160 3.7 Delay in seeking medical attention during labour 153 3.5 Delay in referring patient for secondary/tertiary treatment 121 2.8 No response to maternal hypertension 107 2.5 Infrequent visits to antenatal clinic 61 1.4 Other medical personnel associated factors 49 1.1 Other patient associated factors 43 1 Incorrect management of antepartum haemorrhage 43 1

Hypertension Number % of deaths

Deaths due to complications of hypertension 6053 HEALTH CARE PROVIDER ASSOCIATED 1759 29.1 PATIENT AND FAMILY ASSOCIATED 1630 26.9 ADMINISTRATIVE PROBLEMS 372 6.1 Inappropriate response to poor fetal movements 627 10.4 No response to maternal hypertension 507 8.4 Delay in referring patient for secondary/tertiary treatment 337 5.6 Booked late in pregnancy 293 4.8 Never initiated antenatal care 271 4.5 Failed to return on the prescribed date 101 1.7 Infrequent visits to antenatal clinic 92 1.5 Delay in seeking medical attention during labour 90 1.5 Declines admission/treatment for personal/social reasons 62 1 No dedicated high risk clinic at referral hospital 61 1

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Table 15. Avoidable factors that probably impacted on the death of an infant (as assessed by their maternity unit) for each major disease category for babies over 500g (cont.)

Unexplained stillbirths Number % of deaths

Deaths due to unexplained stillbirths 9567 PATIENT AND FAMILY ASSOCIATED 3312 34.6 HEALTH CARE PROVIDER ASSOCIATED 682 7.1 ADMINISTRATIVE PROBLEMS 162 1.7 Inappropriate response to poor fetal movements 1782 18.6 Never initiated antenatal care 454 4.7 Booked late in pregnancy 419 4.4 Delay in seeking medical attention during labour 289 3.0 Inadequate / No advice given to mother 101 1.1 Infrequent visits to antenatal clinic 91 1.0 Other patient associated factors 88 0.9 Other medical personnel associated factors 83 0.9 Failed to return on the prescribed date 65 0.7 Physical examination of patient at clinic incomplete 58 0.6 Delay in referring patient for secondary/tertiary treatment 53 0.6 No response to history of poor fetal movement 52 0.5

Immaturity related Number % of deaths

Neonatal deaths due to immaturity related 9273 PATIENT AND FAMILY ASSOCIATED 2826 30.5 HEALTH CARE PROVIDER ASSOCIATED 1503 16.2 ADMINISTRATIVE PROBLEMS 970 10.5 Delay in seeking medical attention during labour 977 10.5 Never initiated antenatal care 815 8.8 Inadequate facilities/equipment in neonatal unit/nursery 407 4.4 Booked late in pregnancy 284 3.1 Inappropriate response to poor fetal movements 190 2.0 Neonatal care: management plan inadequate 182 2.0 Nosocomial infection 161 1.7 No accessible neonatal ICU bed with ventilator 123 1.3 Delay in referring patient for secondary/tertiary treatment 116 1.3 Neonatal care: inadequate monitoring 115 1.2 Antenatal steroids not given 112 1.2 Neonatal resuscitation inadequate 107 1.2

Hypoxia Number % of deaths

Deaths due to hypoxia 1507 PATIENT AND FAMILY ASSOCIATED 449 29.8 HEALTH CARE PROVIDER ASSOCIATED 219 14.5 ADMINISTRATIVE PROBLEMS 119 7.9 Never initiated antenatal care 105 7 Inappropriate response to poor fetal movements 93 6.2 Booked late in pregnancy 65 4.3 Delay in seeking medical attention during labour 40 2.7 No response to positive syphilis serology test 26 1.7 Infrequent visits to antenatal clinic 21 1.4 Delay in seeking help when baby ill 19 1.3 Inadequate facilities/equipment in neonatal unit/nursery 18 1.2 Failed to return on the prescribed date 16 1.1 Delay in referring patient for secondary/tertiary treatment 15 1

In approximately 5% of perinatal deaths there was a direct human resources issue. This is probably higher as other avoidable factors, missed opportunities and sub-standard care also include some human resource factor, for example delay in referring a patient. Further the assessments of the

25

death are performed at the site where the death occurred, so the reporting of this factor is mostly likely to be under-reported.

Table 16. Direct human resources issues

Health care provider issues All grades Probable % deaths Personnel not sufficiently trained to manage patient 371 198 0.7% Personnel too junior to manage patient 179 87 0.4% Insufficient doctors available 258 159 0.6% Insufficient nurses available 404 264 1.0% Delay in doctor responding to call 341 208 0.7% Doctor not respond to call 114 84 0.2% Delay in calling for expert advice 712 386 2.7% Delay in referring patient* 1829 1058 4.3% Anaesthetic delay* 217 194 0.5% *- Other issues also play a role in these factors

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1.9 Summary of findings 1. PPIP gives good quality of care assessments in Free State, Mpumalanga, North Wes, and

Western Cape; moderate in Limpopo and Northern Cape and poor in Eastern Cape, Gauteng and KwaZulu-Natal.

2. Sample size good, all levels of care well represented 3. Comparisons with 2010-2011 show similar values 4. The mortality rates per birth weight category are higher than expected for district hospitals in

the 1000g-1999g categories, especially in early neonatal deaths 5. Perinatal care index highest in district hospitals 6. Unexplained stillbirth is the largest category of macerated stillbirths across all levels of care 7. Intrapartum birth asphyxia is the most common category in fresh stillbirths in CHCs and district

hospitals 8. Most deaths occur in district hospitals, as well as most births. Mortality rates were the highest

in district hospitals. BUT on average one district hospital will deliver a live born baby between 1000g and 1999g once every 5 days, and 12% (one in eight will be an early neonatal death). That is for the average district hospital delivering 2000 babies per year. If the hospital delivers 500 live babies per year, then they will deliver a live born between 1000g and 1999g every 20 days and two will die per year. The issue of resources that should be available, the cost effectiveness of district hospitals and accessibility are highlighted.

9. Most caesarean sections are performed in district and regional hospitals with the regional hospitals averaging 4 per day with the district hospitals averaging 1 per day (for an average of 2000 births per year). If the hospital does less than 500 deliveries per year, it will likely do less than 1 caesarean section per week. There is concern about maintaining skill levels for the surgery and anaesthetic at such frequencies.

10. Almost half of the deaths due to intrapartum asphyxia were thought to be probably preventable; the common problems being with fetal monitoring, use of the partogram and the second stage of labour.

11. Inadequate facilities were the most common avoidable factor in spontaneous preterm labour 12. In almost a third of babies dying due to complications of hypertension, hypertension was

detected but NOT acted upon. 13. In almost one in five deaths which were unexplained stillbirths the patient was reported as not

responding to poor fetal movements 14. Deaths due to immaturity were thought to be probably preventable if better facilities were

available to the neonates 15. Health care provider issues were relatively rarely reported, but are significant in their nature.

Unprofessional behaviour was found by doctors not responding to calls and lack of training also featured.

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1.10 Recommendations NaPeMMCO made its recommendations in 2011 for the 2008-2010 triennium. The recommendations are summarised as HHAPINESS.

• Health system improvement • Health care provider training • Reduced deaths due to Asphyxia • Reduce deaths due to Prematurity • Reduce deaths due to Infection

This is incorporated in the Neonatal Survival Strategy These recommendations still hold to day. However, to help achieve HHAPINESS some basic building blocks of the health system need to be in place. These are:

• Knowledgeable and skilled health care providers • Appropriately resourced health care facilities (including equipment and human resources) • Rapid inter-facility emergency transport system

These three key functions must be available to all pregnant women (including the less informed and most disadvantaged people). To achieve this attention should be paid to the How and Who. This can be summarised as the 5Cs How Who Care: Commitment to quality

- DCSTs to improve clinical governance, clinical supervision, response to local audit findings, and leadership functions

- HCP to make themselves available for training and to participate in drills

- Managers to ensure emergency drills performed regularly Coverage - District managers to ensure all effective interventions are

implemented in maternity, especially for the poorest section of the population

- EMS to ensure transport home to institution and between institutions

CPAP - CEOs and district managers rationalise resources to ensure skills and facilities available 24/7

- HCP have skills institute nasal CPAP Contraception - All HCP to motivate people to prevent unwanted pregnancies

- Managers to ensure various modalities are always available - WBOTs to identify women requiring contraception, and refer

Community involvement - Health facility management to engage with community health committees

- WBOTs convey the essential maternity and baby care messages to all pregnant and postnatal women

HCP – Health Care Professional; DCSTs – District Clinical Specialist Teams; CEOs – Chief Executive Officers; WBOTs – Ward Based Outreach Teams; CS - Caesarean Section

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Monitoring and evaluation The effect of implementation of these recommendations can be monitored and evaluated by assessing the emergency obstetric care signal functions. This can be linked with the neonatal emergency care signal functions as some of the major neonatal emergency care signal functions occur in the antenatal period. This will promote the integration of maternal and neonatal services. Table 1 shows the obstetric and neonatal signal functions.

Table 1. Obstetric and neonatal signal functions.i

Dimensions of Facility Care Obstetric Neonatal

General requirements for health facility

Service availability 24/7

Skilled providers in sufficient numbers

Referral service to higher-level care, communication tools

Reliable electricity and water supply, heating in cold climates, clean toilets

A. Routine care (for all mothers and babies)

Monitoring and management of labour using partograph Thermal protection

Infection prevention measures (hand-washing, gloves) Immediate and exclusive breastfeeding

Active management of third stage of labour (AMTSL) Infection prevention including hygienic cord care

HIV and TB Screening and treatment PMTCT if HIV-positive mother

B. Basic emergency care (for mothers and babies with complications)

Parenteral magnesium sulphate for (pre-) eclampsia Antibiotics for preterm or prolonged PROM to prevent infection

Assisted vaginal delivery Corticosteroids in preterm labour

Parenteral antibiotics for maternal infection Resuscitation with bag and mask of non-breathing baby

Parenteral oxytocic drugs for haemorrhage KMC for premature/very small babies

Manual removal of placenta for retained placenta Alternative feeding if baby unable to breastfeed

Removal of retained products of conception Injectable antibiotics for neonatal sepsis

ARVs for mother

C. Comprehensive emergency care (functions in addition to Basic)

Surgery (e.g., C-section) including anaesthesia Intravenous fluids

Blood transfusion Safe administration of oxygen

The signal functions are measures of life saving services, thus giving Magnesium Sulphate is a measure of being able to manage severe hypertension and eclampsia; ability to give oxytocin is a measure of being able to manage obstetric haemorrhage etc. 1Adapted from Gabrysch S, Civitelli G, Edmond KM, Mathai M, Ali M, et al. (2012) New Signal Functions to Measure the Ability of Health Facilities to Provide Routine and Emergency Newborn Care. PLoS Med 9(11): e1001340.doi:10.1371/journal.pmed.1001340

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Section 2

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2.1 Mortality indices for provinces and districts for babies 500g+ (from PPIP 2012-2013)

Provinces All birth weights Stillbirths ENND Total

Deaths Live births 500g+ 500g+ 500g+

Districts 500g+ 500g+ 500g+ 500g+ 500g+ PNMR SBR ENNDR . - Eastern Cape 142371 3259 1797 5056 139112 35.51 22.89 12.92 .. + Alfred Nzo 11143 181 113 294 10962 26.38 16.24 10.31 .. + Amathole 40142 1047 512 1559 39095 38.84 26.08 13.10 .. + Cacadu 12888 285 121 406 12603 31.50 22.11 9.60 .. + Chris Hani 33442 638 361 999 32804 29.87 19.08 11.00 .. + Joe Gqabi 306 11 6 17 295 55.56 35.95 20.34 .. + NM Metro 15103 220 51 271 14883 17.94 14.57 3.43 .. + OR Tambo 24570 809 577 1386 23761 56.41 32.93 24.28 .. + Ukhahlamba 4777 68 56 124 4709 25.96 14.23 11.89

. - Free State 89563 2556 1157 3713 87007 41.46 28.54 13.30 .. + Fezile Dabe 16233 438 219 657 15795 40.47 26.98 13.87 .. + Lejweleputswa 22688 612 328 940 22076 41.43 26.97 14.86 .. + Mangaung 24468 778 320 1098 23690 44.87 31.80 13.51 .. + T Mofutsanyane 23947 679 265 944 23268 39.42 28.35 11.39 .. + Xhariep 2227 49 25 74 2178 33.23 22.00 11.48

. - Gauteng 290656 6320 2594 8914 284336 30.67 21.74 9.12 .. + Ekurhuleni 113121 2463 1164 3627 110658 32.06 21.77 10.52 .. + Jhb Metro 45540 941 542 1483 44599 32.56 20.66 12.15 .. + Sedibeng 29922 627 205 832 29295 27.81 20.95 7.00 .. + Tshwane 69425 1147 501 1648 68278 23.74 16.52 7.34 .. + West Rand 32648 1142 182 1324 31506 40.55 34.98 5.78

. - KwaZulu Natal 204660 5364 2411 7775 199296 37.99 26.21 12.10 .. + Amajuba 1159 12 7 19 1147 16.39 10.35 6.10 .. + eThekwini 45546 1460 543 2003 44086 43.98 32.06 12.32 .. + iLembe 1507 40 13 53 1467 35.17 26.54 8.86 .. + Sisonke 17690 324 236 560 17366 31.66 18.32 13.59 .. + Ugu 20515 473 195 668 20042 32.56 23.06 9.73 .. + uMgungundlovu 19141 578 260 838 18563 43.78 30.20 14.01 .. + Umkhanyakude 15090 295 138 433 14795 28.69 19.55 9.33 .. + Umzinyathi 15379 267 186 453 15112 29.46 17.36 12.31 .. + Uthukela 19726 543 299 842 19183 42.68 27.53 15.59 .. + Uthungulu 35846 1119 417 1536 34727 42.85 31.22 12.01 .. + Zululand 13061 253 117 370 12808 28.33 19.37 9.13

. - Limpopo 207829 4594 2530 7124 203235 34.28 22.10 12.45 .. + Capricorn 49160 1300 651 1951 47860 39.69 26.44 13.60 .. + Mopani 39077 979 613 1592 38098 40.74 25.05 16.09 .. + Sekhukhune 41968 890 450 1340 41078 31.93 21.21 10.95 .. + Vhembe 56746 974 547 1521 55772 26.80 17.16 9.81 .. + Waterberg 20878 451 269 720 20427 34.49 21.60 13.17

. - Mpumalanga 156466 3526 1574 5100 152940 32.59 22.54 10.29 .. + Ehlanzeni 77617 1531 830 2361 76086 30.42 19.73 10.91 .. + Gert Sibande 36669 898 351 1249 35771 34.06 24.49 9.81 .. + Nkangala 42180 1097 393 1490 41083 35.32 26.01 9.57

. - North West 109347 2533 958 3491 106814 31.93 23.16 8.97 .. + Bojanala 36698 872 302 1174 35826 31.99 23.76 8.43 .. + Dr K Kaunda 23356 593 227 820 22763 35.11 25.39 9.97 .. + NM Molema 30325 690 304 994 29635 32.78 22.75 10.26 .. + Ruth Segomotsi 18968 378 125 503 18590 26.52 19.93 6.72

31

Provinces All birth weights Stillbirths ENND Total

Deaths Live births 500g+ 500g+ 500g+

Districts 500g+ 500g+ 500g+ 500g+ 500g+ PNMR SBR ENNDR . - Northern Cape 37923 998 460 1458 36925 38.45 26.32 12.46 .. + Frances Baard 12564 384 180 564 12180 44.89 30.56 14.78 .. + JT Gaetsewe 10058 281 112 393 9777 39.07 27.94 11.46 .. + Namakwa 2521 47 25 72 2474 28.56 18.64 10.11 .. + Pixley ka Semme 5946 93 66 159 5853 26.74 15.64 11.28 .. + Siyanda 6834 193 77 270 6641 39.51 28.24 11.59

. - Western Cape 181549 3708 1244 4952 177841 27.28 20.42 7.00 .. + CT Metro 121578 2585 738 3323 118993 27.33 21.26 6.20 .. + Cape Winelands 15624 287 98 385 15337 24.64 18.37 6.39 .. + Central Karoo 2326 61 25 86 2265 36.97 26.23 11.04 .. + Eden 17097 353 144 497 16744 29.07 20.65 8.60 .. + Overberg 15241 271 167 438 14970 28.74 17.78 11.16 .. + West Coast 9683 151 72 223 9532 23.03 15.59 7.55

32

2.2 Mortality indices for provinces and districts for babies 1000g+ (from PPIP data 2012-2013)*

Provinces All births SB ENND All deaths Live births PNMR SBR ENND Districts 1000g+ 1000g+ 1000+ 1000g+ 1000g+ 1000g+ 1000g+ 1000g+ . - Eastern Cape 140956 2608 1341 3949 138348 28.02 18.50 9.69 .. + Alfred Nzo 11100 165 96 261 10935 23.51 14.86 8.78 .. + Amathole 39599 820 337 1157 38779 29.22 20.71 8.69 .. + Cacadu 12711 193 75 268 12518 21.08 15.18 5.99 .. + Chris Hani 33241 557 287 844 32684 25.39 16.76 8.78 .. + Joe Gqabi District 302 8 6 14 294 46.36 26.49 20.41 .. + NM Metro 14970 147 33 180 14823 12.02 9.82 2.23 .. + OR Tambo 24273 657 457 1114 23616 45.89 27.07 19.35 .. + Ukhahlamba 4760 61 50 111 4699 23.32 12.82 10.64

. - Free State 88219 1877 840 2717 86342 30.80 21.28 9.73 .. + Fezile Dabe 16060 340 179 519 15720 32.32 21.17 11.39 .. + Lejweleputswa 22355 433 235 668 21922 29.88 19.37 10.72 .. + Mangaung 23893 508 209 717 23385 30.01 21.26 8.94 .. + T Mofutsanyane 23711 561 198 759 23150 32.01 23.66 8.55 .. + Xhariep 2200 35 19 54 2165 24.55 15.91 8.78

. - Gauteng 286808 4734 1651 6385 282074 22.26 16.51 5.85 .. + Ekurhuleni 111729 1761 751 2512 109968 22.48 15.76 6.83 .. + Jhb Metro 44855 611 304 915 44244 20.40 13.62 6.87 .. + Sedibeng 29672 479 151 630 29193 21.23 16.14 5.17 .. + Tshwane 68048 779 316 1095 67269 16.09 11.45 4.70 .. + West Rand 32504 1104 129 1233 31400 37.93 33.97 4.11

. - KwaZulu Natal 201921 3977 1643 5620 197944 27.83 19.70 8.30 .. + Amajuba 1154 11 5 16 1143 13.86 9.53 4.37 .. + eThekwini 44777 1024 307 1331 43753 29.73 22.87 7.02 .. + iLembe 1487 28 8 36 1459 24.21 18.83 5.48 .. + Sisonke 17567 267 193 460 17300 26.19 15.20 11.16 .. + Ugu 20278 361 134 495 19917 24.41 17.80 6.73 .. + uMgungundlovu 18723 385 163 548 18338 29.27 20.56 8.89 .. + Umkhanyakude 14974 215 109 324 14759 21.64 14.36 7.39 .. + Umzinyathi 15308 235 155 390 15073 25.48 15.35 10.28 .. + Uthukela 19456 406 210 616 19050 31.66 20.87 11.02 .. + Uthungulu 35256 842 277 1119 34414 31.74 23.88 8.05 .. + Zululand 12941 203 82 285 12738 22.02 15.69 6.44

. - Limpopo 206051 3842 1915 5757 202209 27.94 18.65 9.47 .. + Capricorn 48463 1012 449 1461 47451 30.15 20.88 9.46 .. + Mopani 38723 818 461 1279 37905 33.03 21.12 12.16 .. + Sekhukhune 41724 795 378 1173 40929 28.11 19.05 9.24 .. + Vhembe 56438 849 425 1274 55589 22.57 15.04 7.65 .. + Waterberg 20703 368 202 570 20335 27.53 17.78 9.93

. - Mpumalanga 155029 2851 1159 4010 152178 25.87 18.39 7.62 .. + Ehlanzeni 76999 1268 609 1877 75731 24.38 16.47 8.04 .. + Gert Sibande 36398 744 276 1020 35654 28.02 20.44 7.74 .. + Nkangala 41632 839 274 1113 40793 26.73 20.15 6.72

. - North West 108084 1963 700 2663 106121 24.64 18.16 6.60 .. + Bojanala 36324 676 217 893 35648 24.58 18.61 6.09 .. + Dr K Kaunda 22957 403 144 547 22554 23.83 17.55 6.38 .. + NM Molema 29961 562 233 795 29399 26.53 18.76 7.93 .. + Ruth Segomotsi 18842 322 106 428 18520 22.72 17.09 5.72

33

Provinces All births SB ENND All deaths Live births PNMR SBR ENND Districts 1000g+ 1000g+ 1000+ 1000g+ 1000g+ 1000g+ 1000g+ 1000g+ . - Northern Cape 37212 701 272 973 36511 26.15 18.84 7.45 .. + Frances Baard 12196 237 78 315 11959 25.83 19.43 6.52 .. + JT Gaetsewe 9978 232 96 328 9746 32.87 23.25 9.85 .. + Namakwa 2483 28 14 42 2455 16.92 11.28 5.70 .. + Pixley ka Semme 5861 72 39 111 5789 18.94 12.28 6.74 .. + Siyanda 6694 132 45 177 6562 26.44 19.72 6.86

. - Western Cape 178342 2191 605 2796 176151 15.68 12.29 3.43 .. + Cape Town Metro 119358 1543 378 1921 117815 16.09 12.93 3.21 .. + Cape Winelands 15426 171 45 216 15255 14.00 11.09 2.95 .. + Central Karoo 2275 32 13 45 2243 19.78 14.07 5.80 .. + Eden 16743 206 63 269 16537 16.07 12.30 3.81 .. + Overberg 14989 159 67 226 14830 15.08 10.61 4.52 .. + West Coast 9551 80 39 119 9471 12.46 8.38 4.12

*- Eastern Cape, Gauteng and KwaZulu-Natal have more than 25% of births not registered on PPIP and the data for them must be treated with caution.

34

2.3

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talit

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nked

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dis

tric

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PN

MR,

SBR

and

EN

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Dist

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PN

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1000

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1000

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ENN

D 10

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Di

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PNM

R 10

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SB

R 10

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10

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1000

g+

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1000

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13.6

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87

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20.4

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